FCEMS Volunteer Application Form
Personal Information
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Only select one of the following membership types.
Type of Membership
*
EMS Member
Associate Member
Auxiliary Member
Basic Requirements
EMS Membership
Are you 18 years of age or older?
Do you possess a valid Virginia Driver’s License and a good driving record?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you understand that you must maintain minimum certifications of Virginia EMT, EVOC and AHA CPR to remain on the EMS Membership roster?
Additional Comments
Basic Requirements
Associate Membership
Are you 18 years of age or older?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you have plans to obtain a Virginia EMT certification?
Additional Comments
Basic Requirements
Axillary Membership
Are you 18 years of age or older?
Do you possess a valid Virginia Driver’s License and a good driving record?
Do you understand that applicants will be required to provide Criminal Background check sanctioned by the Virginia Office of EMS?
Do you understand that you must maintain minimum certifications of EVOC and AHA CPR to remain on the Auxiliary Membership roster?
Additional Comments
Availability
Station Preference
*
Station 1 (Town of Floyd)
Station 3 (Locust Grove)
Station 4 (Indian Valley)
Please select your availability for the given days and time phases
*
Monday - Days
Monday - Nights
Tuesday - Days
Tuesday - Nights
Wednesday - Days
Wednesday - Nights
Thursday - Days
Thursday - Nights
Friday - Days
Friday - Nights
Saturday - Days
Saturday - Nights
Sunday - Days
Sunday - Nights
If accepted by FCEMS Volunteer Division, you will be required to maintain certifications applicable to the membership type offered. Can you meet this requirement?
*
If accepted by FCEMS Volunteer Division, you will be required to provide service based on the Assigned Duty hours described in the membership type offered. Can you meet this requirement?
*
Are you willing and able to wear an emergency pager or radio and respond to emergencies?
*
Are you willing and able to participate in mandated skills assessment and training programs?
*
Skills and Experience
Please indicate if you have any of the following certifications or training
*
CPR - Cardiopulmonary resuscitation
Virginia EMT
Virginia Paramedic
Emergency Vehicle Operation (EVOC)
Rescue procedures- extrication, rope rescue, etc.
Various Fire certifications
Other
Previous EMS Experience - Explain:
Previous Volunteer Experience - Explain:
References
Please provide atleast 1 character treference and atleast 1 professional reference.
Terms and Conditions
Please verify that you are human
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: